Female Sexual Conditions

Pain during intercourse, dyspareunia, is one of the most common complaints of women.  Dyspareunia, is not one specific disease. Instead, it is a symptom with many different causes.  Patients with provoked vulvodynia or vestibulodynia may experience severe burning, cutting, or searing, raw-like pain at the opening to the vagina upon some sort of provocation such as Q-tip (cotton swab) testing or upon initial vaginal penetration. Generalized vulvodynia or vestibulodynia is used if the pain exists all the time and is not related to provocation. Vestibulodynia may be the result of many different causes. These may include inflammatory and infectious disease processes, neurologic conditions, genetic factors, stress factors, and hormone factors. As a result, one management strategy for all women with complaints of vulvar pain will likely not be successful.
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When specifically addressing provoked vestibulodyna (PVD), the most common causes are hormonal changes, tight (hypertonic) pelvic floor muscles, and an increased number of nerve endings in the mucosa of the vestibule.  The genital region may have other types of dysesthesia, such as itching, rather than pain.  These reponses may be a result of injury to the cauda equina.

Persistent genital arousal disorder (PGAD) is associated with unrelenting, unwanted, persistent, intrusive, and spontaneous sensations such as pressure/discomfort, engorgement, pulsating, pounding and/or throbbing in the genital tissues and/or in the perineum and/or anus in the absence of conscious thoughts of sexual desire or sexual interest. Persistent genital arousal disorder is often associated with significant personal bother and distress. Men and women with PGAD are often ashamed for having inappropriate genital feelings and often having suicidal thoughts.

Instead of pain, sometimes the genitalia and/or thighs are itchy despite there being no evident pathology to cause this to occur.  This area is innervated by nerves that may be sending the wrong signal to the brain which interprets a feeling of itchiness or priuritis, causing you to want to scratch, even though there is no actual irritation on the itchy surface.

Restless legs is similar to persistent genital arousal disorder in that movements are taking place with no control, spontaneously at specific times or throughout the day.

Interstitial cystitis (IC) (also known as Painful Bladder Syndrome) is a condition in which the bladder lining becomes severely inflamed. The causes frequent urination (up to 60 times a day!) and severe pelvic pain and dysapareunia. Seventy-five percent of women with IC say that sex makes their pain and need to urinate worse.  While there are probably many different causes that start IC it is most commonly reported to start after “severe urinary tract infection” Hormonal, neurologic, immunologic, genetic, infectious, and environmental factors all play a role in the initiation of IC. Hypertonic pelvic floor muscle dysfunction frequently accompanies IC. An additional causes is Injury to the bladder mucosa.  Injury to the cauda equna which causes vestibular pain may also be responsible for triggering a genito-pelvic dysesthesia response which appears to be IC.

Lack of genital sensation may feel like a man is wearing 10 condoms.  For a woman she may only be able to feel very strong thrusts (which may cause pain elsewhere) or not at all due to nerve injury.  Nerve testing can help determine where that injury is located.

Anorgasmia is a sexual orgasmic disorder in which there is persistent and consistent inability to achieve orgasm, after adequate stimulation that causes personal distress. Anorgasmia can be caused by psychologic problems or medical problems such as diabetic neuropathy, multiple sclerosis, or complications from spinal cord injury, genital surgery, radical prostatectomy, pelvic trauma, hormonal issues such as low testosterone and low thyroid. A common cause of anorgasmia is the use of anti-depressants, particularly selective serotonin reuptake inhibitors (SSRIs).  Anorgasmia may also be caused by lack of genital sensation due to injury in the cauda equina.

Women with pleasure dissociative orgasmic disorder or orgasmic anhedonia can achieve orgasm but derive no pleasure from it.  It is thought that they have a dysfunction in regulation of the brain neurochemical dopamine in the region of the brain’s reward center, the nucleus accumbens. This region of the brain is thought to play an important role in reward, laughter, pleasure, addiction, and music.  It may be caused by psychologic issues such as depression or drug addiction, or by physiologic issues such as high levels of prolactin, low levels of testosterone, use of medications such as SSRI antidepressants, chronic medical problems such as spinal cord injury, and chronic fatigue syndrome.  For some men and women, it may associated with lack of genital sensation leading to lack of pleasure.